Effectiveness of nurse-led preoperative assessment

JBI Library of Systematic Reviews

JBL000304

2010;8(15):621-660

Effectiveness of nurse-led preoperative assessment services for elective surgery: a systematic review 1,2

Sonia Hines 2,3 Anne Chang 2,4 Mary-Anne Ramis 2,5 Shannon Pike . 1. Clinical Research Nurse, MSc candidate 2. Nursing Research Centre and The Queensland Centre for Evidence-based Nursing and Midwifery, Mater Health Services, A collaborating centre of the Joanna Briggs Institute 3. Professor of Clinical Nursing and Director, Queensland University of Technology and Mater Health Services 4. Research Nurse 5. Research Nurse Intern. Corresponding author: Sonia Hines Email: [email protected]

Executive summary Background The admission and assessment of patients for elective procedures is a task faced by all healthcare organisations that provide elective surgical services. Several different strategies have been used to facilitate the management of these tasks. Nurse-led preadmission clinics or services have been implemented in many health services as one of these management strategies; however their effectiveness has not been established. Objectives The objective of this review was to examine the available research on the effectiveness of nurse-led elective surgery preoperative assessment clinics or services on patient outcomes. Inclusion criteria Types of participants The review considered studies that included adult or paediatric patients who were undergoing any type of elective surgical procedure, either as a day-only case or as an inpatient. Types of interventions The review considered studies that evaluated the effect of attending or receiving the services of a nurse-led elective surgery outpatient preadmission or preoperative assessment clinic. Types of outcomes This review considered studies that included the following outcome measures: length of stay, cancellation of surgery, incidence of non-attendance for scheduled surgery, mortality, morbidity, adverse surgical events, preoperative preparation, recognition and fulfilment of postoperative care needs, patient anxiety and reducing the number of overnight stays for day or ambulatory surgery patients. Types of studies The review considered any randomised controlled trials published after 1999; in the absence of RCTs other research designs, such as non-randomised controlled trials and before and after studies, were

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considered for inclusion in a narrative summary to enable the identification of current best evidence regarding the effectiveness of nurse-led preoperative assessment services. Exclusion criteria This review excluded studies of preoperative education as this has been the subject of a previous review. We also excluded studies of emergency admissions. Additionally, studies comparing nurse-led with physician-led preadmission assessments were excluded as that has also been the subject of a previous systematic review. Search strategy The search strategy aimed to find both published and unpublished studies. A three-step search strategy was utilised in each component of this review. An initial limited search of MEDLINE and CINAHL was undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe articles. A second search using all identified keywords and index terms was then undertaken across all included databases. Thirdly, the reference list of all identified reports and articles was searched for additional studies. Methodological quality Papers selected for retrieval were assessed by two independent reviewers for congruence to the review's inclusion criteria, using a tool developed for the purpose. Methodological validity was assessed by two reviewers prior to inclusion in the review using standardised critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI). Data collection/extraction Data were extracted from papers included in the review using the standardised data extraction tool from JBI-MAStARI. Data synthesis Due to the methodological heterogeneity of the included studies, no statistical pooling was possible and all results are presented narratively. Results Of the 19 included articles, there were 10 audits of patient and hospital data, 3 surveys or questionnaires, 3 descriptive studies, 1 action research design, 1 prospective observational study and 1 RCT. Five of ten studies reporting data on cancellations rates found that nurse-led preadmission services reduced the number of day-of-surgery cancellations. Non-attendance for surgery was also reduced, with nine studies reporting decreases in the number of patients failing to attend. Eight studies reporting data on patient or parent satisfaction found high levels of satisfaction with nurse-led preadmission services. Three of four studies investigating the effect of the nurse-led preadmission service on patient anxiety found a reduction in reported anxiety levels. Three studies found that preoperative preparation was enhanced by the use of a nurse-led preadmission service. Conclusions While all included studies reported evidence of effectiveness for nurse-led preadmission services on a wide range of outcomes for elective surgery patients, the lack of experimental trials means that the level of evidence is low, and further research is needed. Implications for practice Nurse-led preadmission services may be an effective strategy for reducing procedural cancellations, failure to attend for procedures, and patient anxiety, however currently the evidence level is low.

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Nurse-led preadmission services may improve patient preparation, recognition of postoperative needs and patient/parent satisfaction with the surgical process; however the current evidence level is low.

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There is little evidence to suggest that nurse-led preadmission services have an effect on adverse surgical events or morbidity.

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There is no evidence to suggest that nurse-led preadmission services have an effect on mortality rates.

Implications for research Currently the overall level of evidence regarding nurse-led preadmission services is low and further more rigorous studies are required for all the examined outcomes. There is little evidence regarding the effect of this intervention on length of stay, mortality rates and morbidity, and therefore more research is needed on the effect of nurse-led preadmission services on these important outcomes. Keywords Nursing assessment, preoperative care, healthcare management, resource use, elective surgery.

Introduction Background The admission and assessment of patients for elective surgery is a task faced by all healthcare organisations that provide elective surgical services. The safe management of surgical patients requires ensuring that they are fit to undergo anaesthesia and that they are 1 able to provide informed consent to the procedure . Several different strategies have been used to facilitate the management of these tasks, such as preoperative assessment by general practitioners, hospital medical staff or nursing staff, either on the day of surgery or 2 prior to admission . Nurse-led preadmission clinics or services have been implemented in many health services as one of these management strategies. The process of preadmission testing and/or screening involves a wide variety of procedures, depending on the needs of the facility and the patients. Preadmission clinics or services address several different domains of practice: collection of biometric and psychosocial data, screening to ensure patients receive the most appropriate care whilst in hospital, screening for potential problems that may impact on length of stay, and the provision of education and information on the planned procedure and hospital process. The main benefit of beginning this process at the preadmission stage appears to be that it provides increased time for data collection, especially history taking, which is a vital part of 3 the pre-surgical work-up . Histories taken on the day of surgery may be less than complete, due to patient anxiety and the pressure of time on the nurse. Historically, medical personnel have provided these services and in some healthcare systems 4 this remains the case . However shortages of medical staff and the high cost of services have meant that nursing staff have taken over these tasks and indeed, nurses are in an ideal position to manage and provide these services. Nurse-led preoperative clinics may offer a 5 more holistic service and a broader range of expertise than medical assessments alone . In addition, many patients find nurse-led preoperative assessment as acceptable as medical 4, 6 assessment .

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A comparative study of patients being assessed prior to elective cardiac surgery found no differences in quality or safety between assessments conducted by junior medical staff and those conducted by appropriately trained nurses in terms of major adverse events; minor clinical adverse events; the senior cardiologist’s (who was responsible for the diagnostic cardiac catheter) overall satisfaction with the preparation of the patient; the patient's satisfaction with the preadmission clinic assessment for diagnostic day case cardiac catheter; 4 and duration of the preadmission clinic . Preoperative patient assessment is vital to identify patient risk factors, to provide information and education and to perform and/or arrange any necessary measurements or laboratory 3, 5, 7 studies such as blood tests or electrocardiographs . Thorough assessment of surgical patients has been shown to help to prepare them physically and psychologically for their 8 hospital experience . Preoperative assessment may also address the anxiety many patients feel regarding anaesthesia and the surgical experience. Explanation of the procedure and the process the patient will go through may help to increase patient knowledge and decrease their anxiety. Decreased anxiety is a significant factor in patients' feelings of satisfaction with the surgical 5 process as a whole . The advantage of preadmission assessment is that patients who have had their questions answered and their concerns alleviated prior to their admission will usually 5 enter the process with a lower level of anxiety . Early assessment of patients booked for day surgery can also reduce the number of day of 5, 9, 10 surgery cancellations , and unexpected overnight stays and the associated strain on 7, 8 inpatient bed numbers . Last-minute cancellation of surgery has costs for both hospitals 10 and patients and is a largely avoidable occurrence in most cases . Cancellations and unexpected overnight stays are both considered to be indicators of poor preoperative 11 assessment and/or preparation . Preoperative assessment in preadmission clinics may also allow for screening of patients with 12 13 14 a variety of tools for risks such as delirium , nutrition problems , the presence of MRSA , 15 16 tobacco use , or lack of home support all of which can have a serious effect on length of 9 stay, and the course and cost of postoperative recovery . The use of screening tools at the preadmission stage allows for a level of preparation for the hospital stay that may not otherwise be possible. For the paediatric patient, preoperative preparation can lead to an 17 increase in compliance with procedures , as well as a reduction in post-operative pain and 18 sleep disturbance . This review aims to examine whether nurse-led preoperative assessment clinics or services improve surgical outcomes for patients, and reduce day-of-surgery cancellations and length of 19 stay. An existing review by Bazian compared the effectiveness of nurse-led to physician-led services, and consequently, this outcome will not be included in this review. Preoperative 20-23 education has also been the subject of several previous reviews and this review aims to fill the remaining gap in the existing evidence.

Glossary Day surgery: The process by which suitable patients are admitted for a planned surgery on 24 the day of the procedure and return home the same day . Elective surgery: Non-emergency surgical procedures which are booked and planned at least 25 24 hours in advance of the procedure time . Preoperative assessment: A process by which it is ensured that a patient is fit for surgery and 1 anaesthetic, and informed about their surgical procedure . Hines et al.


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Emergency admission: A patient admission to hospital, usually through an emergency 25 department or casualty, that is not booked or planned . 25

Inpatient: A patient admitted to hospital that stays at least one night in a hospital facility . Failure to arrive/non-attendance for surgery: A patient scheduled for a procedure who does 11 not arrive at the facility on the required day or make contact to cancel the procedure Cancellation of surgery: The non-performance of the planned surgery for any reason, either 11 doctor or patient-related, after the patient has arrived at the facility .

Objectives The objective was to review the available research on the effectiveness of nurse-led elective surgery preoperative assessment clinics or services on patient outcomes. More specifically, the objectives were to identify the effectiveness of nurse-led preoperative assessment services on reducing adverse surgical events, improving patient satisfaction, decreasing anxiety, reducing inpatient days and reducing the number of overnight stays for day or ambulatory surgery patients.

Inclusion criteria Types of studies The review considered any randomised controlled trials (RCTs) published after 1999; in the absence of RCTs other research designs, such as non-randomised controlled trials and before and after studies, were considered for inclusion in a narrative summary to enable the identification of current best evidence regarding the effectiveness of nurse-led preoperative assessment services. Exclusion criteria This review excluded studies of preoperative education as this has been the subject of a previous review. We also excluded studies of emergency admissions. Studies comparing nurse-led with physician-led preadmission assessments were excluded as that has also been the subject of a previous systematic review. Types of participants The review considered studies that included adult or paediatric elective surgery patients who were having any type of surgical procedure, either as a day surgery case or as an inpatient. Types of intervention The review considered studies that evaluated the effect of attending or receiving the services of a nurse-led outpatient preadmission or preoperative assessment clinic. Types of outcome measures This review considered studies that included the following outcome measures: length of stay, cancellation of surgery, incidence of non-attendance for scheduled surgery, mortality, morbidity, adverse surgical events, preoperative preparation, recognition and fulfilment of postoperative care needs, patient anxiety and patient or parent satisfaction.

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Search strategy The search strategy aimed to find both published and unpublished English-language studies. A three-step search strategy was utilised in each component of this review. An initial limited search of MEDLINE and CINAHL was undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe article. A second search using all identified keywords and index terms was then undertaken across all included databases. Thirdly, the reference lists of all identified reports and articles were searched for additional studies. (See Appendix I) The following databases were searched for published studies: MEDLINE CINAHL Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library) EMBASE (1999 to present) Meditext (1999 to present); ISI Web of Science (1999 to present). The following databases were searched for unpublished studies: Current Controlled Trials Clinical Study Results OpenSIGLE New York Academy of Medicine Library Grey Literature Report MEDNAR National Institute of Clinical Studies (NHMRC) Science.gov Initial keywords used were: 1. preoperative or preadmission or pre$admission 2. assessment or examination or work-up or investigation or screening 3. clinic or service or team 4. nurs*

Method of the review Assessment of congruence to review criteria Retrieved papers were assessed for congruence to the review's inclusion criteria using a tool developed by authors and based on the recommendations of the Cochrane Collaboration (Appendix II).

Assessment of methodological quality Papers selected for retrieval were assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardised critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix III). Any disagreements that arose between the reviewers were resolved through discussion between the reviewers.

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Data collection/extraction Data were extracted from papers included in the review using the standardised data extraction tool from JBI-MAStARI (Appendix IV). The data extracted included specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives.

Data synthesis Due to the heterogeneity of methods used by the included studies, no statistical pooling was possible and all results are summarised narratively.

Review results Description of studies Extensive searches of databases and the Internet identified 2853 papers, with 737 duplicates. After checking the titles and abstracts, 106 potentially relevant articles were selected for further review of the full paper. Articles were checked for congruence with the review’s inclusion and exclusion criteria, and their reference lists checked for potentially relevant studies. Sixteen further studies were sourced from the reference lists. After comparing the full version of 122 articles with the inclusion and exclusion criteria, 25 studies proceeded to critical appraisal by two independent reviewers. Six further articles were excluded following critical appraisal, leaving 19 included studies for data extraction. Details of included studies can be found in Appendix V and details of excluded studies are in Appendix VI. A description of the study identification process can be found below in Figure 1.

Database and internet searches: n=2853

Studies identified from reference lists and bibliographies: n=16

Duplicates removed: n=737

Potentially relevant articles retrieved: n=122

Outside inclusion criteria: n=97

Studies meeting inclusion criteria: n=25

Excluded following critical appraisal: n=6 Included studies: n=19 Figure 1. Study identification process 8, 26-34

Of the 19 included articles, 10 were audits of patient and hospital data , 3 were surveys 35-37 9, 38, 39 40 or questionnaires , 3 were descriptive studies , 1 action research design , 1 41 42 prospective observational study and 1 RCT . Studies were conducted in Australia, New Zealand, the United Kingdom, and the USA. Studies included adult and paediatric patients

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and examined preadmission clinics or services for patients undergoing either in-patient or day case surgery. The included studies examined the effects of the intervention on more than 9552 participants (number not exact due to missing data in two studies).

Methodological quality Methodological quality was low to moderate across all included studies. As stated above, of 8, 26-34 the 19 included articles, 10 were audits of patient and hospital data , 3 were surveys or 35-37 9, 38, 39 40 questionnaires , 3 were descriptive studies , 1 action research design , 1 prospective 41 42 observational study and 1 RCT .

Results 9, 26-32, 37, 39

Ten studies reported data on day-of-surgery cancellation rates and five of the ten found that nurse-led preadmission services reduced the number of cancellations. Non8, 9, 26, 27, 29, 30, 33, 35, 39 attendance for surgery was also reduced, with nine studies reporting decreases in the number of patients failing to attend. Eight studies reporting data on patient or 8, 30, 31, 36-38, 40, 43 parent satisfaction found high levels of satisfaction with nurse-led 27, 31, 35, 42 preadmission services. Three of the four studies on the effect of the nurse-led 27, 28, 35 preadmission service found a reduction in patient anxiety. Three studies found that preoperative preparation was enhanced (in terms of patient understanding of the procedure, or necessary preoperative tasks such as fasting being undertaken) by the use of a nurse-led preadmission service. We extracted data on a wide range of outcomes for the included studies, although we were not able to find data for all planned outcome measures (described below) and therefore findings are reported narratively and in tables where appropriate. Length of stay 32

One study reported findings on the effect of the nurse-led preadmission clinic on length of stay. In this audit of 119 gynaecology patients in New Zealand, the average length of stay was reduced from 1.1 to 0.8 days per patient. This facility utilised a preadmission health questionnaire, which was mailed out to patients, to identify those patients requiring further assessment in the preadmission clinic prior to their procedure in the day surgery unit. Cancellation of surgery 9, 26-28, 30-32, 37, 39

Nine studies reported data on the effect of nurse-led preadmission services on 26-28, 31, 37 rates of surgery cancellation. Of the five studies measuring this outcome and utilising 26, 27, 31, 37 a historical comparison group, four studies found that the introduction of a nurse-led preadmission service led to a decrease in the number of procedural cancellations. Due to the nature of the various non-experimental study designs, it is not possible to make a more conclusive statement of a causal relationship and study findings are presented in Table 1 (Appendix VIII). Incidence of non-attendance for scheduled surgery 8, 9, 26, 27, 29, 30, 33, 39

Eight studies collected data on the number of patients failing to attend for 8, 9, 27, 29 their scheduled procedures. Four of the eight studies, reported historical comparison data and found that rates of non-attendance had been decreased, however, as with the previous outcome, the study designs do not allow a conclusive cause and effect statement to be made and the findings are summarised in Table 2 (Appendix VIII).

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Interestingly, in the study by Digner et al a further comparison was made between patients whose preadmission assessment was conducted via telephone and those whose assessment was conducted in a face-to-face clinic. It was found that not only did non-attendance rates decrease over the data collection period, but those patients assessed by the telephone service had non-attendance rates approximately half that of patients seen in person by the clinic. In 2005, 1.4% of patients screened via telephone failed to attend compared to 2.9% of patients seen in the preadmission assessment clinic. Mortality No included studies reported data on mortality rates. Morbidity and adverse surgical events 33

Only one study reported data on adverse surgical events. In a comparison of patients 33 assessed in a nurse-led tonsillectomy preadmissions clinic to national registry data, Wu et al found that there were 5 episodes of bleeding complications recorded at the study facility (4.7%), which was slightly less than the national (UK) average of 5.7% (no statistical significance reported). Preoperative preparation 27, 28, 35

Three studies assessed the effect of nurse-led preadmission services on preoperative preparation needs such as understanding of the procedure, understanding of preparation requirements such as fasting, and/or booking a suitable time for surgery. Patient 27 understanding of their procedure was reported to be high by Bennetts et al at 81%, in their single group survey of 1040 patients. Those patients requiring language assistance were less well served, with only 4% reporting that they had benefited from the preadmission clinic. 28

In Bird's study of paediatric admissions 12% of parents surveyed responded that they had not had sufficient information, however none of these had attended the preadmission clinic, whereas the 88% who had attended with their child, responded that they had enough information and felt well-prepared. 35

The surgical patients surveyed by Clark et al reported finding the nurse-led preadmission service effective in meeting their preoperative needs. Greater than 90% of respondents felt the preadmission clinic (PAC) helped them understand the purpose of surgery; more than 90% understood why they needed to fast preoperatively; 50% agreed the preadmissions clinic helped them book a suitable appointment; and more than 95% understood the purpose of attending PAC. Recognition and fulfilment of postoperative care needs 27, 35, 39, 41

Four studies examined how nurse-led preadmissions services may improve the recognition and fulfilment of postoperative care needs such as communicating aftercare instructions or requirements for transportation, postoperative concerns or questions, or 27 planning for discharge destination. Bennetts et al report that following the introduction of a nurse-led preadmission service, 100% of patients audited stated that they knew who to contact postoperatively if they had any questions. Similarly, 85% of participants in Clark et al's 35 study reported that they understood their aftercare instructions better after attending the nurse-led clinic. 41

Boyer et al trialled the use of nurse-led preoperative screening to predict discharge destination. Of 277 screened pts, 163 were identified as needing post-acute care, but actually only 44 (27%) were eventually enrolled into home health care. Nine patients screened as needing home health care actually went to a post-acute facility instead of home. Pre-

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screening was not able to predict the actual discharge destination (χ = 42.63, df= 6, P < 0.001). Post-hoc analysis showed the home health care group was significantly older. The study authors concluded that they were unable to show any benefit in this method of prescreening for discharge planning. 39

In a study of admissions to an elective surgery centre in the UK, Rai et al found that despite nursing assessment preoperatively, there were still 18 unplanned transfers to other hospitals; four of which should have been predicted at the preoperative assessment stage. This represents only a small percentage of the total number of patients seen (0.14%), however, it is still regarded as a system failure by the authors. Patient anxiety 27, 31, 35, 42

Four studies reported data on the effect of the nurse-led preadmission service on 27 patient anxiety. Of the patients surveyed by Bennetts et al , 25% reported less anxiety after 35 their preadmission clinic visit and of those surveyed by Clark et al 80% agreed that the 31 preadmission clinic helped to reduce anxiety. Paediatric nurses in Sexton et al's study reported perceiving that 61.1% of their patients who had attended the preadmission clinic experienced less anxiety. However, the group randomised to attend the preadmission clinic 42 by Rose et al was not found to have any less anxiety than the non-clinic-attending control group (P = 0.472) and it may be that this finding would be repeated in further high quality studies. Patient or parent satisfaction 8, 30, 31, 34, 36-38, 40

Eight studies examined this outcome . Satisfaction was variously measured as satisfaction with nursing care, satisfaction with time spent waiting, satisfaction with the preoperative preparation process, or satisfaction with the information provided. From the reported data, it appears that patients and/or parents were very satisfied with the preadmission clinic services they received. 31, 36

Satisfaction with waiting time was measured by two studies , both of which report that respondents to their surveys were satisfied with the amount of time spent waiting during the admission and assessment process. Overall satisfaction with the preadmission process 8, 30, 34, 37, 38, 40 through the nurse-led service was measured by six studies , all of which found that respondents reported high levels of satisfaction with the service they had received. 40 Additionally, 97% of respondents to the survey conducted by Walsgrove et al reported that they were satisfied with the information they had received and it was useful and easy to understand. Study findings for this outcome are summarised in Table 3 (Appendix VIII).

Discussion Surgical cancellations, either due to poor patient preparation, previously unidentified medical issues, or non-attendance by the patient, represent a significant challenge to many health 44-46 systems . Twelve of the nineteen studies included in this review have measured the effectiveness of their preadmissions service in terms of cancellation of surgery, either by the doctor or by the patient's non-attendance, and have found that the use of a nurse-led preadmission service may provide sufficient assessment, information and guidance to reduce the numbers of patients whose booked surgery does not proceed. The services represented in the included studies used a variety of strategies to assess patients preoperatively. Most utilised a physical clinic which the patients were asked to attend in the preoperative period to be assessed and prepared for surgery, however some studies 9, 26, 29, 39 achieved results through the use of telephone assessments or mailed questionnaires . Hines et al.


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Those services utilising telephoned or mailed assessments reported very low levels of non-attendance and it may well be that these simple, low-cost strategies could be utilised with good effect in other settings. It seems more likely, however, that different strategies will be effective for different patient groups, cultures and countries. In clinical settings such as endoscopy where correct preparation is essential to the procedure, nurse-led preadmission services have been shown to be effective in ensuring that patients are properly prepared, which can reduce the number of cancelled procedures and failures to 27 attend . Comprehensive preoperative preparation does not only include physical needs, however, and an essential part of preoperative assessment is to gauge the postoperative needs of the patient and ensure that they understand the postoperative care instructions and any limitations there may be on their activities, such as driving, in the period following their 27 procedure . Nurses are ideally placed to provide the type of holistic care required to fully prepare patients for the surgical process. Patients report valuing the opportunity to spend time with a nurse 35 and ask questions, receive information, and to discuss their fears and concerns . Improved communication and information has been shown by several included studies to have reduced 27, 31, 35 patient and/or parent anxiety . It is interesting to note, however, that the only experimental trial able to be included in this review found no evidence of a reduction in patient 42 anxiety after attending a nurse-led preadmission service . These conflicting findings may be due to the propensity of unconcealed, non-randomised studies such as those included here to 47 overestimate evidence of an effect , so further research is clearly required to ensure the reported effects are in fact due to the intervention and not some other cause. Patients do appear to be satisfied with the care they receive through nurse-led preadmission services. Many of the included studies measured patient satisfaction with various aspects of their services and all found that the majority of patients expressed satisfaction with their care. The lack of comparison groups in almost all the included studies makes it impossible to know whether patients would have been equally or more satisfied with other models of care, but given the other positive findings made by the same studies, it seems likely that nurse-led preadmission services are effective and satisfactory to patients.

Conclusion The evidence included in this review indicates that nurse-led preadmission services may reduce length of stay, cancellations of surgery, incidence of non-attendance for scheduled surgery and patient anxiety, enhance preoperative preparation, recognition and fulfilment of postoperative care needs, and improve patient or parent satisfaction. Although the included studies strongly favour the effectiveness of nurse-led preadmission services, the lack of randomised controlled trials or other high level evidence means that no definitive conclusions about the effectiveness of this intervention can be made.

Implications for practice •

Nurse-led preadmission services may be an effective strategy for reducing procedural cancellations, failure to attend for procedures, and patient anxiety, however currently the evidence level is low.

•

Nurse-led preadmission services may improve patient preparation, recognition of postoperative needs and patient/parent satisfaction with the surgical process; however the current evidence level is low.

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There is little evidence to suggest that nurse-led preadmission services have an effect on adverse surgical events or morbidity.

•

No studies were identified that provided any evidence regarding the effect of nurse-led preadmission services on mortality rates.

Implications for research Currently the overall level of evidence regarding nurse-led preadmission services is low and further more rigorous studies are required for all the examined outcomes. There is little evidence regarding the effect of this intervention on length of stay, mortality rates and morbidity, and therefore more research is needed on the effect of nurse-led preadmission services on these important outcomes.

Limitations This review was limited by the inclusion of exclusively English-language articles and we acknowledge the potential bias this brings to our findings. Our search parameters (19992010) mean that it is possible we may have excluded potentially useful studies published outside these dates.

Acknowledgements We would like to acknowledge the support of the Nursing Research Centre, Mater Health Services, Brisbane, during the writing of this review. The authors thank Ms Ruth Hollin for her comments and input during the protocol development process.

Conflict of interest None known.

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Melbourne, Australia2001 [cited 2010 29/06]; Available from: http://www.surgeons.org/Content/NavigationMenu/WhoWeAre/Affiliatedorganisations/ AustraliaDaySurgeryCouncil/Day_Surgery_Endoscop.htm#Indicator_area_1. Litaker D, Locala J, Franco K, Bronson DL, Tannous Z. Preoperative risk factors for postoperative delirium. General Hospital Psychiatry 2001;23(2):84-9. Schwartz D, Gudzin D. Preadmission Nutrition Screening: Expanding Hospital-Based Nutrition Services By Implementing Earlier Nutrition Intervention. Journal of the American Dietetic Association 2000;100(1):81-7. Diller R, Sonntag AK, Mellmann A, Grevener K, Senninger N, Kipp F, et al. Evidence for cost reduction based on pre-admission MRSA screening in general surgery. International Journal of Hygiene and Environmental Health 2008;211(1-2):205-12. Wolfenden L, Dalton A, Bowman J, Knight J, Burrows S, Wiggers J. Computerized assessment of surgical patients for tobacco use: accuracy and acceptability. Journal of Public Health 2007. Liebergall M, Soskolne V, Mattan Y, Feder N, Segal D, Spira S, et al. Preadmission screening of patients scheduled for hip and knee replacement: impact on length of stay. Clin Perform Qual Health Care 1999;7(1):17-22. Brewer S, Gleditsch SL, Syblik D, Tietjens ME, Vacik HW. Pediatric anxiety: child life intervention in day surgery. Journal of pediatric nursing 2006;21(1):13-22. Kain ZN, Mayes LC, Caldwell-Andrews AA, Karas DE, McClain BC. Preoperative anxiety, postoperative pain, and behavioral recovery in young children undergoing surgery. Pediatrics 2006;118(2):651. Bazian Ltd. Preoperative assessment by nurses. Evidence-Based Healthcare and Public Health 2005;9(6):376-80. McDonald S, Hetrick SE, Green S. Pre-operative education for hip or knee replacement Cochrane Database of Systematic Reviews 2004(1). Johansson K, Nuutila L, Virtanen H, Katajisto J, Salantera S. Preoperative education for orthopaedic patients: systematic review. Journal of Advanced Nursing 2005;50(2):212-23. Lee A, Chui PT, Gin T. Educating patients about anesthesia: a systematic review of randomized controlled trials of media-based interventions. IARS; 2003. p. 1424-31. Hodgkinson B, Evans D, O’Neill S. Knowledge Retention from Pre-operative Patient Information. . The Joanna Briggs Institute for Evidence Based Nursing and Midwifery 2000;Report No. 6. Gandhimani P, Jackson IJB. UK guidelines for day surgery. Surgery (Oxford) 2006;24(10):346-9. Data Collections Unit, Queensland Health. Queensland Hospital Admitted Patient Data Collection (QHAPDC) In: Queensland Health, editor. Brisbane2010. Basu S, Babajee P, Selvachandran S, Cade D. Impact of questionnaires and telephone screening on attendance for ambulatory surgery. Annals of the Royal College of Surgeons of England 2001;83(5):329. Bennetts J, Rollins F. Endoscopy: pre admission clinic -- 'reducing the risk, improving patient outcomes'. JGENCA 2006;16(4):16-22. Bird M. The anaesthetic nurse specialist in the pre-admission clinic. Paediatric Nursing 1999 Oct;11(8):19-22. Digner M. At your convenience: preoperative assessment by telephone. Journal of perioperative practice 2007;17(7):294-8, 300-1. Ryan P. The benefits of a nurse-led preoperative assessment clinic. Nursing Times. [Evaluation Studies]. 2000 Sep 28-Oct 4;96(39):42-3. Sexton K, Redfearn M. Preadmission testing in a children's facility. AORN Journal 2003;78(4):604-17. Whitham D. Nurse-led gynaecology pre-admission clinic trial. Dissector 2006;34(2):20-2. Wu K, Walker E, Owen G. Nurse-led 'one stop' clinic for elective tonsillectomy referrals. Journal of Laryngology and Otology 2007;121(4):378-81. Kelly M, Sweet A, Watson C. Advancing the NP role in presurgical care. Profile of success at a pediatric hospital. Advance for nurse practitioners 2001;9(10):77. Clark K, Voase R, Cato G, Fletcher IR, Thomson PJ. Patients' experience of oral day

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case surgery: feedback from a nurse-led pre-admission clinic. Ambulatory Surgery 2000;8(2):93-6. Harris C, Watson P. The benefit of nurse-led pre-assessment. Kai Tiaki Nursing New Zealand 2005;11(3):16-8. Stokes-Roberts A. Pre-admission clinics. Smooth operators. Health Service Journal 1999 Jan 7;109(5636):22-3. Kirkwood B, Pesudovs K, Latimer P, Coster D. The efficacy of a nurse -led preoperative cataract assessment and postoperative care clinic. Medical Journal of Australia 2006 2006 Mar 20;184(6):278-81. Rai MR, Pandit JJ. Day of surgery cancellations after nurse-led pre-assessment in an elective surgical centre: the first 2 years. Anaesthesia 2003 Jul;58(7):692-9. Walsgrove H. Piloting a nurse-led gynaecology preoperative-assessment clinic. Nursing Times 2004;100(3):38-41. Boyer CL, Wade DC, Madigan EA. Prescreening cardiothoracic surgical patient population for post acute care services. Outcomes Management for Nursing Practice 2000 Oct-Dec;4(4):167-71. Rose K, Waterman, H., Toon., McLeod, D. & Tullow, A. Organising day-surgery for cataract: selecting the outcome measures Opthalmic Nursing: International Journal of Opthalmic Nursing 1999;2(4):14-20. Wittkugel EP, Varughese AM. Pediatric preoperative evaluation - A new paradigm. International Anesthesiology Clinics 2006 Dec;44(1):141-58. Schofield W, Rubin G, Piza M, Lai Y, Sindhusake D, Fearnside M, et al. Cancellation of operations on the day of intended surgery at a major Australian referral hospital. Med J Aust 2005;182(12):612-5. El-Dawlatly A, Turkistani A, Aldohayan A, Zubaidi A, Ahmed A. Reasons Of Cancellation Of Elective Surgery In A Teaching Hospital. The Internet Journal of Anesthesiology 2008;15(2). Seim A, Fagerhaug T, Ryen S, Curran P, Sather O, Myhre H, et al. Causes of Cancellations on the Day of Surgery at Two Major University Hospitals. Surgical Innovation 2009. Kunz R, Oxman A. The unpredictability paradox: review of empirical comparisons of randomised and non-randomised clinical trials. British Medical Journal 1998;317(7167):1185.

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Appendix I: Search strategies MEDLINE (1999-2010) via EBSCO Host 1. (MH)Admitting Department, Hospital 2. (MH)Preoperative Care 3. (MH)Patient Admission 4. pre-admission OR preadmission 5. preoperative OR pre-operative 6. 1 OR 2 OR 3 OR 4 OR 5 7. (MH)Nursing Assessment 8. examination 9. clerking 10. investigation 11. screening 12. 7 OR 8 OR 9 OR 10 OR 11 13. (MH)Outpatient Clinics, Hospital 14. clinic 15. service 16. team 17. 13 OR 14 OR 15 OR 16 18. (MH) Models, Nursing 19. (MH)Nursing Staff, Hospital 20. nurs* 21. 18 OR 19 OR 20 22. 6 AND 12 AND 17 AND 21 CINAHL (1999-2010) via EBSCO Host 1. (MH)Admitting Department, Hospital 2. (MH)Preoperative Care 3. (MH)Patient Admission 4. pre-admission OR preadmission 5. preoperative OR pre-operative 6. 1 OR 2 OR 3 OR 4 OR 5 7. (MH)Nursing Assessment 8. examination 9. clerking 10. investigation 11. screening 12. 7 OR 8 OR 9 OR 10 OR 11 13. (MH)Outpatient Clinics, Hospital 14. clinic 15. service 16. team 17. 13 OR 14 OR 15 OR 16 18. (MH) Models, Nursing 19. (MH)Nursing Staff, Hospital 20. 18 OR 19 OR 20

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21. 6 AND 12 AND 17 AND 20 CENTRAL 1. (MH)Admitting Department, Hospital 2. (MH)Preoperative Care 3. (MH)Patient Admission 4. pre-admission OR preadmission 5. preoperative OR pre-operative 6. 1 OR 2 OR 3 OR 4 OR 5 7. (MH)Nursing Assessment 8. examination 9. clerking 10. investigation 11. screening 12. 7 OR 8 OR 9 OR 10 OR 11 13. (MH)Outpatient Clinics, Hospital 14. clinic 15. service 16. team 17. 13 OR 14 OR 15 OR 16 18. (MH) Models, Nursing 19. (MH)Nursing Staff, Hospital 20. 18 OR 19 OR 20 21. 6 AND 12 AND 17 AND 20 MEDITEXT via INFORMIT (1999 – Present) 23. Admitting AND Department AND Hospital 24. Preoperative AND Care 25. Patient AND Admission 26. pre-admission OR preadmission 27. preoperative OR pre-operative 28. 1 OR 2 OR 3 OR 4 OR 5 29. Nursing AND Assessment 30. examination 31. clerking 32. investigation 33. screening 34. 7 OR 8 OR 9 OR 10 OR 11 35. Outpatient AND Clinics OR Hospital 36. clinic 37. service 38. team 39. 13 OR 14 OR 15 OR 16 40. Models AND Nursing 41. Nursing AND Staff OR Hospital 42. nurs* 43. 18 OR 19 OR 20 44. 6 AND 12 AND 17 AND 21

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EMBASE via OVID (CKN) (1999 – Present) 1. Admitting Department AND Hospital 2. Preoperative AND Care 3. Patient AND Admission 4. pre-admission OR preadmission 5. preoperative OR pre-operative 6. 1 OR 2 OR 3 OR 4 OR 5 7. Nursing AND Assessment 8. examination 9. clerking 10. investigation 11. screening 12. 7 OR 8 OR 9 OR 10 OR 11 13. Outpatient AND Clinics AND Hospital 14. clinic 15. service 16. team 17. 13 OR 14 OR 15 OR 16 18. Models AND Nursing 19. (MH)Nursing AND Staff AND Hospital 20. nurs* 21. 18 OR 19 OR 20 22. 6 AND 12 AND 17 AND 21 EMBASE via Elsevier (library) (1999 – Present) 1. Admitting Department AND Hospital 2. Preoperative AND Care 3. Patient AND Admission 4. pre-admission OR preadmission 5. preoperative OR pre-operative 6. 1 OR 2 OR 3 OR 4 OR 5 7. Nursing AND Assessment 8. examination 9. clerking 10. investigation 11. screening 12. 7 OR 8 OR 9 OR 10 OR 11 13. Outpatient AND Clinics AND Hospital 14. clinic 15. service 16. team 17. 13 OR 14 OR 15 OR 16 18. Models AND Nursing 19. (MH)Nursing AND Staff AND Hospital 20. nurs* 21. 18 OR 19 OR 20 22. 6 AND 12 AND 17 AND 21

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WEB of SCIENCE (1999 – Present) used TS = (hospital AND admitting AND department) 1. Admitting Department AND Hospital 2. Preoperative AND Care 3. Patient AND Admission 4. pre-admission OR preadmission 5. preoperative OR pre-operative 6. 1 OR 2 OR 3 OR 4 OR 5 7. Nursing AND Assessment 8. examination 9. clerking 10. investigation 11. screening 12. 7 OR 8 OR 9 OR 10 OR 11 13. Outpatient AND Clinics AND Hospital 14. clinic 15. service 16. team 17. 13 OR 14 OR 15 OR 16 18. Models AND Nursing 19. (MH)Nursing AND Staff AND Hospital 20. nurs* 21. 18 OR 19 OR 20 22. 6 AND 12 AND 17 AND 21 Grey literature search Controlled Trials www.controlled-trials.com 1. hospital AND admitting AND department 2. (hospital AND pre-admission AND clinic) 3. preoperative And care 4. (preoperative AND care AND assessment) 5. (pre-admission AND clinic) 6. (outpatients AND clinics AND hospital) 7. (preoperative AND Care And Patient AND Admission) 8. pre-admission OR preadmission 9. preoperative OR pre-operative 10. (preoperative OR pre-operative) AND nursing AND assessment 11. examination 12. clerking 13. investigation 14. screening 15. clinic 16. service 17. team 18. nursing AND models 19. nursing AND model 20. nursing and staff and hospital 21.(preadmission or pre-admission) and Nursing assessment 22. preadmission AND nursing AND service Hines et al.


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23.pre-admission AND nursing AND service 24. preoperative AND Nursing AND assessment OpenSigle http://www.opensigle.inist.fr/ 1. preadmission 2. preoperative 3. presurgical

New York Academy of Medicine Library Grey Literature Report http://nyam.waldo.kohalibrary.com/cgi-bin/koha/opac-search.pl 1. hospital admitting department 2. preoperative care 3. patient admission 4. preadmission or pre-admission 5. preoperative or pre-operative 6. hospital outpatients clinic 7. nursing assessment 8. (preoperative OR pre-operative) AND screening 9. clerking 10. investigation 11. screening 12. nursing model 13. preoperative or pre-operative nursing care

National Institute of Clinical Studies (NHMRC) http://www.nhmrc.gov.au/nics/index.htm preadmission or pre-admission preoperative or pre-operative nursing assessment

Science.gov http://www.science.gov/browse/w_127.htm 1. preoperative nurse assessment 2. preadmission clinic 3. hospital admitting department 4. patient admission 5. preadmission or pre-admission 6. preoperative or pre-operative 7. nursing assessment 8. examination 9. clerking 10. clerking AND preadmission 11. clerking AND pre-admission 12. investigation 13. investigation AND preoperative

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14. investigation AND preadmission 15. investigation AND pre-admission 16. screening 17. screening AND preoperative 18. screening AND pre-operative 19. screening AND preadmission 20. pre-admission AND screening 21. hospital outpatients clinic 22. hospital outpatients clinic AND nurse 23. hospital outpatients clinic AND nursing assessment 24. nursing assessment 25. nursing assessment AND outpatient 26. nursing assessment AND clinic 27. nursing assessment AND clinic AND pre-operative

MEDNAR http://mednar.com/ preadmission AND nursing preoperative or pre-operative nursing assessment preadmission AND screening preoperative AND screening preoperative AND evaluation preadmission AND evaluation

Clinical Study Results http://www.clinicalstudyresults.org/home/ preadmission or pre-admission preoperative or pre-operative nursing assessment

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Appendix II: Verification of Study Eligibility Form Nurse-led Preadmissions Clinics SR VERIFICATION OF STUDY ELIGILIBILITY INCLUSION CRITERIA AUTHOR AND YEAR

JOURNAL TITLE

NAME/CODE OF REVIEWER Setting:

Acute hospital or surgical day facility

Yes

No

Population:

Adults or children having surgical procedures

Yes

No

Intervention: Participants are attending or receiving the services of a nurse-led outpatient preadmission or preoperative assessment clinic Yes No Study Design: Study is original quantitative research Date: Study was published 1999 or later

Yes

No

Yes

No

IF YOU HAVE NOT ANSWERED YES TO ALL OF THE ABOVE QUESTIONS, YOU SHOULD EXCLUDE THE STUDY. IF YOU ANSWERED YES TO ALL, PLEASE CONTINUE. Language: Does the study require translation before it can be appraised?

Yes

No

If yes, please arrange for translation before proceeding Exclusions: Does the study examine preoperative education, emergency admissions, or compare nurse-led with physicianled preadmission assessments? Yes No If yes, please exclude the study.

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Appendix III: Critical Appraisal Tools JBI-MAStARI critical appraisal form (descriptive studies) Author:

Record No:

Journal:

Year:

Reviewer: Criteria

Yes

1

Was the study based on a random or pseudo-random sample?

2

Were the criteria for inclusion in the sample clearly defined?

3

Were confounding factors identified and strategies to deal with them stated?

4

Were outcomes assessed using the objective criteria?

5

If comparisons are being made, was there sufficient description of the groups?

6

Was follow up carried out over a sufficient time period?

7

Were the outcomes of people who withdrew described and included in the analysis?

8

Were outcomes measured in a reliable way?

9

Was appropriate statistical analysis used?

Include: Yes

No

No

N/A

Seek further info

Reasons:

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Unclear


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JBI MAStARI Critical Appraisal of Experimental studies

Reviewer

Date

Author

Year

Record No

1. Was the assignment to treatment groups random? Yes

No

Not clear

NA

2. Were the participants blinded to treatment allocation? Yes

No

Not clear

NA

3. Was allocation to treatment groups concealed from the allocator? Yes

No

Not clear

NA

4. Were the outcomes of people who withdrew described and included in the analysis? Yes

No

Not clear

NA

5. Were those assessing the outcomes blind to the treatment allocation? Yes

No

Not clear

NA

6. Were control and treatment groups comparable at entry? Yes

No

Not clear

NA

7. Were groups treated identically other than for the named interventions? Yes

No

Not clear

NA

8. Were outcomes measured in the same way for all groups? Yes

No

Not clear

NA

9. Were outcomes measured in a reliable way? Yes

No

Not clear

NA

10. Was there adequate follow-up of participants (>80%)? Yes

No

Not clear

NA

11. Was appropriate statistical analysis used? Yes

No

Overall appraisal:

Include

Not clear

Exclude

NA

Seek further info

Comments (including reasons for exclusion)

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Appendix IV: Data Extraction Tools JBI-MAStARI Data Extraction Tool (descriptive and experimental studies) Author:

Record No:

Journal:

Year:

Reviewer: Method Setting Participants # Participants Interventions Authors conclusions

Reviewers comments

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Appendix VI: Table of Included Studies

Study

Method

Setting

Aims

Participants

Outcomes

Basu S, Babajee P, Selvachandran S, Cade D. 200126

audit

UK hospital day surgery unit

Reduce surgery cancellations or postponements

566 patients scheduled for surgery

Cancellations, failure to attend, postponements

Bennetts J, Rollins F. 200627

audit

Australian day endoscopy unit

Improve the admission to discharge process; reduce clinical and financial risks

1040 patients having endoscopy

Cancellations, anxiety, failure to attend, discharge planning, patient preparation

Bird M. 1999 28

audit

UK paediatric hospital

Improve patient preparation for surgery; reduce cancellations; improve use of theatre time

170 children having dental or maxillo-facial surgery

Patient preparation, blood tests, cancellations

Boyer CL, Wade DC, Madigan EA. 200041

Prospective observational pilot study of predictive factors

USA tertiary hospital

Identify patients postoperative needs during preadmission visits in order to improve discharge process

277 adult cardiothoracic pts (CABG n=133) (Valve n=84) (Other cardiac n=60)

Discharge planning

Clark K, Voase R, Fletcher IR, Thomson PJ. 1999 9

Descriptive

UK oral day surgery unit

Improve failure to attend rate; improve patient preparation; identify patients unfit for surgery earlier in order to improve cancellation rate.

908 pts listed for oral day surg under general anaesthesia. 908 invited to attend, 727 (80%) attended, 629 (69%) proceeded to day surgery. 1997: n=411. 1998: n=497

Failure to attend

Clark K, Voase R, Cato G, Fletcher IR, Thomson PJ. 2000 35

Patient questionnaire

UK oral and maxillofacial unit

Investigate patient perceptions of the preadmission clinic

Consecutive surgical patients operated on between October 1997 and January 1998 178 questionnaires sent. 88 returned (49% response rate)

Cancellations, patient anxiety, post-operative needs, preoperative preparation

Digner M. 2007 29

Audit

UK hospital day surgery unit and telephone nursing advice

Improve theatre utilisation through reducing the number of failure to attend

Patients listed for day surgery with diastolic BP